Sunday, 4 December 2011

Elective 37. I am emergency aid

Today starts with attending the English service at the Christian chapel with Kiwi and Dolittle, after I was pointedly asked yesterday why I had not gone recently by the reverend who lives across from my house. I don't want him to be upset, and though Sporty and Smartie avoided it after he had a stool-over-head waving shouting and screaming "power of the Anglican church" sermon, I haven't really turned up very much so had nothing to lose from showing the service to my new guests. After the service comes the morning meeting. Three deaths are reported from yesterday, fortunately none of them the patients I was trying to look after on the ward, and then we end up doing Dr Bike's ward round again, and in the evening have to try and work out how to treat two seriously ill patients, despite the hospitals lack of supplies. Here, I actually get a chance to make a difference.

The 3 deaths that were reported in the morning meeting were of two still born babies, and an 8 year old child:

The first was that of a mother who came into hospital in the advanced stages of labour at about 32 weeks, but baby had no foetal heart rate. The child was reportedly born with 'severe lacerations' and the reason for the labour was expected to be because the child had died. Abortion is illegal in Tanzania, but without saying as such, it was clear that the nurses at the morning meeting felt that this woman had had the baby injured in her home village so it would be aborted. Just because something is made illegal, it doesn't mean that people won't do it, and in much less safe situations than would be possible at a hospital.

The second death is another still born baby, one of a mother who has been on the maternity ward for about a week waiting to give birth. Unfortunately, when she came to the doctors to tell them she was having contractions, her baby had already died (no foetal heart rate), meaning there is nothing that can be done other than wait for the dead baby to be 'born'. This time, it seemed that the mother had been having contractions for about 8 hours, but had not presented to the doctors when they started, due to the common belief among the women that if they tell the doctors they have started labour and it doesn't progress fast enough, they will have a C-section, so by leaving it as late as possible, they avoid C-section. By leaving it this late, the baby, which was born with the chord wrapped around its neck, was not monitored in the early stages of the labour, and so the distress which would have lead to an emergency C- section being carried out was not detected, which is the main reason for the mother to be in hospital in the first place. Another example of where health education would make a big difference to people's outcomes in hospital.

The final death was an 8 year old child, admitted around 5PM with a haemoglobin of 6g/dl and with all of the clinical signs of severe anaemia. A blood transfusion was ordered for her, and the doctor left her while the lab tec was called in from his home to carry out the cross match (make sure the relatives blood is the correct group). By the time that everyone had had their dinner, and the blood had been typed, the doctor returned at 12.30AM to carry out the transfusion, only to find the child dead. It seems that no-one had come to see how the child was in all of that time. The other two deaths mentioned in the morning meeting were un-preventable. This child should have received their treatment much more promptly. The reasons for the death (in my opinion) either seem to weigh in at incompetence or negligence, but at the meeting, the facts are given, and the case is forgotten, left as a mark in the 'deaths' column in the meeting paperwork. If issues like this are never discussed, then people will never change their practice and things won't get better.

After such a depressing start to the day, Dr Bike is too busy to do a ward round this morning, so proposes that we do it (Kiwi, Dolittle and me), and then explain what we think should be done with each patient when we talk with him later, making it more efficient. On the ward round, it appears that no-one is dying, but a number of patients need relatively urgent reviews by Dr Bike, so we mark these down. We then spend some time playing with a tube of bubble mixture Kiwi has bought with her in the children's ward to cheer up patients and parents. The children start off petrified of the bubbles, and the parents curious, many having obviously never seen these sort of things before. The children start off hiding behind parents and beds of the terrifying mzungu, while the parents are sitting, trying to catch the bubbles, and rubbing their hands or sniffing their fingers afterwards in bemused curiosity. I think it was a wonderful idea to bring  the bubbles, and the children rapidly grew less afraid and more amazed, saying "Majica" (i assume this means magic) as they chased the bubbles around the room. We left the ward very popular that morning, with the children still begging us to keep waving our magic wand.

Kiwi blows bubbles for the children in children's ward. Holly loved trying to catch them, and was full of energy, seeing as she was the only non-sick child on the ward

We found Dr Bike in theatre, removing a subcutaneous lump, though as we were waiting for him to finish, an emergency C-section came in, followed by the plan to change the dressings of the patient with the large abscess on his face (which had been drained, but needed daily dressing changes). It seemed that Dr Bike was going to be some time in theatre, so we returned to the house for a late lunch. During a good chat after lunch, it transpired that Kiwi and Dolittle had felt that, on my first day, they had thought I was a genius, having studied medicine for less time than them, but still able to prescribe sensibly, and knowing all of the correct doses. Today they have unfortunately already realised that there are a few very common diseases, and only about five common drugs. It is a shame that that illusion was shattered so quickly, but at least I looked like a genius for a day!

I return to the ward (alone, as Kiwi and Dolittle want a rest as it is currently very hot) at around the time I would have thought Dr Bike would have finished the surgeries, to find he has left the theatre already. I decide to go to the children's ward to collect the notes for the patients he needs to see together, in the hope he is there, or heading there soon. As I arrive, I am beckoned over by one of the children's parents. The nurses don't seen too bothered by the parents distress, but I persuade one to come and translate for me. The parents think their child has gotten very ill over the last couple of hours, and is getting worse...

This ill baby is about 10 months old, and was admitted with a diagnosis of pneumonia,  gastroenteritis and malaria (it is common for the admitting doctor to try and cover all the bases by diagnosing everything). Tests had shown there was no malaria parasites in the blood, we couldn't listen to the lungs, as she cried whenever we mzungu were near, and has had diarrhoea and vomiting for days in the ward. Last night the doctor on call was called to the ward, as she was having a convulsion. The problem with children crying whenever we try and examine them, or even turn up at the bedside, is so common we don't think about it any more. All the babies here are scared of us, or are a little bit racist. We call it mzungu fever, and it ruins examinations.

In summary, this child has been very sick, though we didn't know what with (assumed gastroenteritis) and now seemed a lot sicker. She was one of the patients we had really wanted Dr Bike to see, though now it seemed a little too late... The baby looked very ill. She was lying on her back in the bed, with her eyes slightly open and not moving at all. I shook her (no response at all), took her pulse ( present but fast, thank god she isn't dead) then quickly examined her body. She had a huge belly, which was bloating out far more than it had been this morning, and sounded resonant on percussion. There were no other obvious problems. The thing that troubled me most was that in all this time with the scary mzungu examining her, the baby hadn't even stirred. This was the child that, for the past few days, we hadn't even been able to listen to her lungs as she was crying so hard every time a mzungu was near her. She was clearly sick. The parents told me that, since the morning when we had seen her (the time was now about 4PM), she had had no more diarrhoea, and had not vomited.

Dr Bike spent most of today in theatre carrying out a number of operations. The theatre is much better kitted out than the rest of the hospital!

I was very worried, and had no idea what was wrong with the baby. Are her bowels obstructed? Or would this cause vomiting? I tried calling Dr Bike four times, but he didn't pick up. Starting to get really worried, I decided to go and look for a doctor to fix things for me. On my way out of the ward, I run into Kiwi and Dolittle, who had felt guilty and come to help me (something I really appreciated right now). I bought them up to date quickly, and we then split up to search the hospital for someone to help us. We found no doctors, but found that the Dr on call was Dr BT. I am not exactly confident of his skill set (he saw the child who died last night of anaemia, who was left for hours without the transfusion) so we decided to get Dr Bike from his house. After all, he still had his ward round to do.

I knocked on his door to find him eating dinner. I explained that there was an emergency, but he said he was busy eating, and would come after he had finished his food. I was sure I wouldn't be able to get him to come in any faster. Dolittle and I head back to the ward, while Kiwi goes back to our house to get her stethoscope, as none of us currently have one on us.

Once back at the ward, I show Dolittle the baby, and Dolittle examines her as well. This time, as soon as Dolittle's fingers touch the baby's head, she stirs and looks around, sneezes in my face (thats another infection coming my way), then lets out a fart lasting for over 10 seconds. I have never heard so much wind in one go, and the abdomen visibly shrinks as she is farting. Not back to normal, but back to a much less scary size. Seemingly relieved, the baby shifts around a little then closes her eyes, and end to our 'emergency' which happens just in time for Kiwi to hurry through the door with her stethoscope in her hand. 

As it terms out, during our search of the hospital for a doctor, I was telling wings how the last time I looked for a doctor in an emergency here, for a child who was crying and writhing with abdominal pain, it turned out to he trapped wind. I was joking about what it would make me look like if this was trapped wind again. How embarrassing for it to happen twice! Perhaps the resonance to percussion should have warned me of this possibility.

Needless to say, when Dr Bike arrived, he seemed a little put out it didn't seem to be the emergency we had made out. Despite the 'downgrading' of this 'life-threatening wind', the child still looked very sick. Dr Bike said that bowel movement can be disturbed  by electrolyte dis-balance, so we should give Ringers Lactate to the child to correct this problem (no capacity to measure electrolytes leaves a lot to guess work). Dr Bike then refused to see the other patients on the ward, and left to go home. A little irresponsible to be in a strop, but I cannot blame him. He had been working in theatre all day, and wasn't ever the doctor on call for us to be troubling.

We decided we should go and check on the other patients who worried us in the morning, but checking out female ward led to new worries. The woman we tried to convince to drink water yesterday and this morning has drunk only 200ml over these two days (we know this as we were providing her with all her water) whilst having diarrhoea every couple of hours. She complained she was too sick feeling to drink water this morning, so we gave her a promethazine injection. Since this morning, she still has not drunk any water, and now does not talk to us or the nurses, she is just lying there, grunting, and weak. She has a thready pulse and a very low blood pressure. She is clearly not well. At this time, the nurse comes in from children's ward to remind us that the Ringers Lactate that Dr Bike ordered is still not in stock, and the only fluids the hospital has is 5% dextrose. This is because boxes and boxes of it were bought for the urologist to use as a flush during the TURPs. It is no good for rehydrating patients. Great, the child can wait. A very sick woman here who really needs fluid, and no available fluids (the 5% dextrose could be dangerous). This is exactly what I didn't want to happen yesterday. The nursing students on the ward were not helpful at all, refusing to trouble her by asking her to try and sit up and drink (as she seemed sleepy), and saying they wouldn't give her fluids if we found them, as the cannula were in short supply on the ward, and they didn't want to wake her from her sleep. The opposite of the child who I was talking about - there the parents were worried and it turned out to be nothing. Here no-one is worried, and I am very sure that something terrible is happening.

Due to the lack of fluids, this clearly needed some kind of Tanzanian-Doctor-Magic to help us, and we decided it would be unfair to bother Dr Bike again. As it was an emergency, we decided to go straight to Chief's home, catching him just as he was getting on his motorbike. I explained the problem, and Chief was happy to come right away and help (right away here, meaning after he had told us about the historical value of the Site of the hospital, and the need to preserve it, but hey, this is Tanzania). I apologised for interrupting his evening, but Chief replied "This is someone's life, this will always be more important'. I love Chief.

I rode on the back of chiefs motorbike the 100 meters between his house and the hospital (why walk when you can ride) arriving at the same time as Kiwi and Dolittle who walked. When at the hospital, Chief quickly examined the woman. His bedside manner is fantastic, talking slowly and gently with the woman, trying to get her to respond. He quickly reached the same conclusion that we did. It is fortunate that I am not embarrassed a third time by calling doctors to patients who are not such, but very unfortunate for the patient, who is very ill.

Chief then spends some time calling up other members of the hospital, trying to get some fluid that is not 5% dextrose, that can be put into the woman, while Kiwi, Dolittle and I wander the wards, checking in cupboards for a single bottle of fluids that has been left there and forgotten that we could use. In maternity we find that they did have one bottle as an emergency, but it had been taken away 30 Minutes ago for children's ward, for the farting baby, by an unusually efficient nurse (annoyingly efficient  now!) So we didn't need to worry about the farting baby any more, but we still needed fluid for the woman.

The search goes on for an awfully long time, but Chief is very persistent. Eventually, 500ml of Ringers Lactate is found, after chief calls the chief nurse in from home to unlock the decontamination room to look in there. I have no idea why it was stored in what is basically a big cleaning cupboard, but very thankful that it was found. We take this, with one of the many 5% dextrose bottles to the patient, and give them both to the very efficient nurse (a real nurse, rather than a nursing student, and it really shows). This is clearly someone we can trust to insert a cannula and run the fluid, and fast. We really would want to give more than a litre, but it is better than nothing. As the efficient nurse sets up the fluid, the patient still hasn't moved and doesn't interact or even flinch away as the cannula is pushed through her skin. If she gets better (and I really hope she does) I will feel that we really contributed to her care. If she gets worse, or dies, at least we did all we could. The whole episode was very exciting, and hopefully similar to that of the job of a junior doctor. Recognising sick patients (hopefully not flatulent patients) and getting appropriate help. I love it!

1 comment:

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